Seclusion & Restraint Report

Seclusion & Restraint Workgroup Report

In 2007, the APNA posted a Position Statement on the Use of Seclusion and Restraint, declaring that “APNA supports a sustained commitment to the reduction and ultimate elimination of seclusion and restraint and advocates for continued research to support evidence-based practice for the prevention and management of behavioral emergencies.”

The position paper described ethical dilemmas inherent in the use of seclusion and restraint, and reviewed research that suggested ways to reduce the use of restrictive interventions and prevent violence. Fundamental principles to guide future action on the issue of seclusion and restraint were articulated. Since 2007, nurses have been working toward eliminating the use of seclusion and restraint, while becoming more focused on recovery and more informed about the effects of trauma. While some have been able to drastically reduce and even eliminate the use of seclusion and restraint, others have, as yet, been unable to achieve this goal.

Ethical Implications

Concerns about the continued use of seclusion and restraint are well justified. Current literature continues to describe the physical and emotional damage that seclusion and restraint use can inflict upon patients, as well as nurses (Kontio et.al, 2010; Pollard & Rogers, 2007). Seclusion and restraint use is an emotionally stressful process that may hinder the therapeutic nurse-patient relationship and increase patient aggression in the unit (Ashcraft & Anthony, 2008; Moran, Cocoman, Scott, Matthews, Staniuliene, & Valimake, et.al, 2009). Nurses and stakeholders are beginning to understand the need for trauma-informed care. The experience of these events has the potential for negative long-term effects that can impede the recovery process (Ryan & Happell, 2009).

Ethically, it is a nurse's responsibility to maintain patient autonomy and dignity (Kontio et al., 2010); however, seclusion and restraint determines the extent of "patient autonomy", thereby diminishing patient integrity. Nurses must balance the responsibility for safeguarding patient rights with the duty to protect patients from harming themselves or others in situations that have escalated to the point of danger (Barton, Johnson, & Price, 2009).

Current Environment

Joint Commission standards (2009) have helped to reinforce the principle that "people have the right to be free from restraint or seclusion as a means of coercion, discipline, convenience, or retaliation." Nurses have been taught that seclusion and restraint are interventions that may be used only as a last resort, after all other intervention attempts have been made (Moran et. al, 2009).

Attitudes, emotions, demographics and experience of the nursing population have been found to influence the use of seclusion and restraint. Nurses who score high in therapeutic optimism and lower in emotional exhaustion are less likely to use seclusion. More experienced nurses are less likely to justify the use of seclusion in care (Happell, & Koehn, 2011). The expression of anger and aggression among team members is a predictor of increased use of seclusion and restraint (De Benedictis et al. 2011). Female nurses are more likely to report feelings of anxiety, frustration, and low morale related to the use of restraint (Happell, & Harrow, 2010).

Literature regarding seclusion and restraint reduction describes the needs of nurses to feel that the last resort use of seclusion and restraints remains an option in unsafe situations that are unable to be resolved by other methods (Barton, Johnson, & Price, 2009). Safety is usually cited as the primary reason for the use of seclusion and restraint. Violence towards self, others and staff, damage to property, and ‘out of control’ behavior are main factors nurses consider in the decision to seclude a patient (Happell, & Harrow, 2010). Hospital leaders need and want compassionate nurses who promote individualized care to recognize cues and help individuals de-escalate before an event occurs (Recupero, Price, Garvey, Daly, & Xavier, 2011). Nurses and stakeholders need adequate staffing to allow time for nurses to focus on the use of non-restrictive interventions to calm patients, prior to an event requiring restraint and seclusion (Recupero, Price, Garvey, Daly, & Xavier, 2011). Consumers of mental health care need and want compassionate care that allows them to be a part of the debriefing process and to reflect on seclusion and restraint events to assist in their recovery process (Ryan & Happell, 2009).

Recommendations

Upon evaluation of the current literature, we present the following recommendations to the APNA Board of Directors toward the use of seclusion and restraint in inpatient psychiatric settings:

Formation of alliances with the following organizations, which have been instrumental in the advocacy of a reduction or elimination of seclusion and restraint use:

American Nurses Association (ANA)

American Psychiatric Association (APA)

Disability Rights Advocates

Consumers (including consumer consultants in the unit)/families

Mental Health America

National Alliance on Mental Illness (NAMI)

National Association of State Mental Health Program Directors (NASMHPD)

Substance Abuse and Mental Health Services Administration (SAMHSA)

The Joint Commission

Formation of an alliance with nursing education programs across the country to evaluate nursing student education on use of seclusion and restraint and to promote a culture of seclusion and restraint use as a “last resort” among future nurses

Advocacy of policy change toward the reduction and eventual elimination of seclusion and restraint use on a state, federal, or organizational level

Appropriation of funds toward the conduction of research projects, particularly of broader and randomized samples

Continuation of the APNA Seclusion and Restraint Task Force toward the production of the APNA Position Paper and Standards on seclusion and restraint

Implementation of a Seclusion and Restraint section in the APNA Resource Center that is accessible to the public in order to educate all nurses, consumers, health care practitioners, and remaining members of the public on the latest standards of seclusion and restraint practice, to educate consumers on their patient rights in inpatient settings, and to advocate for a culture of reduction/elimination of seclusion and restraint

Gaskin, C.J., Elsom, S.J., & Happell, B. (2007). Interventions for reducing the use of seclusion in psychiatric facilities: Review of the literature. British Journal of Psychiatry, 191, 298-303.

Happell, B., & Harrow, A. (2010). Nurses' attitudes to the use of seclusion: a review of the literature. International Journal Of Mental Health Nursing, 19(3), 162-168.

Happell, B., & Koehn, S. (2011). Seclusion as a necessary intervention: the relationship between burnout, job satisfaction and therapeutic optimism and justification for the use of seclusion. Journal Of Advanced Nursing, 67(6), 1222-1231. doi:10.1111/j.1365-2648.

Scanlan, J.N. (2010). Interventions to reduce the use of seclusion and restraint in inpatient psychiatric settings: What we know so far a review of the literature. International Journal of Social Psychiatry, 56, 412-423.

Submitted to the APNA Board of Directors February 2012

The American Psychiatric Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

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